State of North Carolina

PUBLIC WORKS COMMISSION APPLICATION

for GRAVITY SEWERS, PUMP STATIONS, AND FORCE MAINS

(Pressure sewer systems are not to be included as part of this application package)

INSTRUCTIONS: Indicate that you have included the following list of required application package items by checking the space provided next to each item. Failure to submit all required items, and errors and/or omissions in any item in this submittal package, will result in your application being returned as incomplete and/or additional processing and review time. This form must be filled-out digitally.

I. Final Plans – Submit five (5) sets of final (signed & sealed) plans (on bond paper) prepared in compliance with PWC’s standard guidelines, details and specifications, and any other applicable statutes as related to public sanitary sewer systems.

II. PWC Standard Specifications Checklist - Submit one original of the completed checklist indicating all PWC Standard Specifications, which will be adhered to for the construction of this project. A response must be provided to each item on this list.

III. Application Form - Submit one original of the completed and appropriately executed application form. Any errors and/or omissions in this form will result in the application being returned. The Public Works Commission Water Resources Engineering will only accept application packages that have been fully completed with all applicable items addressed. The application should include a project narrative describing the final build-out design (i.e. system and/or pump station to ultimately serve 500 homes, but flow for only 100 homes being requested now). For modifications, clearly explain the reason for the modification (i.e. adding another phase, changing line size/length, etc.). Only include the modified information in this permit application – do not duplicate project information that has already been included in the original permit.

Separate applications should be made for non-contiguous sewer systems.

IV. Application Fee - Submit a check in the amount of $450 made payable to: “Public Works Commission”.

V. Certificates of Public Convenience and Necessity – If the application is being submitted in the name of a privately owned public utility, submit two copies of the Certificate of Public Conveyance and Necessity (CPCN) which demonstrates that the public utility is authorized to hold the utility franchise for the area to be served by the sewer extension. If a CPCN has not been issued, provide two copies of a letter from the North Carolina Utilities Commission’s Public Staff that states than an application for a franchise has been received, that the service area is contiguous to an existing franchised area, and/or that franchise approval is expected. The project name in the CPCN or letter must match that provided in Item A(2)a of this application.

VI. Operational Agreements – Submit one original of a properly executed operational agreement, as per 15A NCAC 02T .0115, if the application is submitted by a private applicant and will be serving residential or commercial lots (e.g., houses, condominiums, townhomes, outparcels, etc.) that will be sold to another entity and not donated to PWC. If the applicant is a homeowners’ association, use Form HOA 02/03. If the applicant is a developer, use Form DEV 02/03. Even if the project may be turned over to a municipality upon completion, form DEV 02/03 is required.

VII. Downstream Sewer, WWTF Capacity, and Flow Tracking/Acceptance - FORM FTSE 10/07 (Flow Tracking/Acceptance for Sewer Extension Permit Applications) is required with every application. The applicant must provide an executed Form FTSE 10/07 from the Public Works Commission with each permit application. The flow acceptance indicated in Form FTSE 10/07 must: not expire prior to permit issuance; be dated less than six (6) months prior to the application date; and shall be for the same volume of wastewater as contained in the permit application.

VIII. Map – Submit an 8.5-inch by 11-inch COLOR copy of the portion of a 7.5-minute USGS Topographic Map along with this form. The map should identify the entire project area location as well as the closest downslope surface waters as clearly as possible. Each map portion must be labeled with the map name and number, the identified location of the sewer line and pump stations, and be of clear and reproducible quality. For instance, if the project involves 4 miles of interceptor sewer that traverses over or near several different waterbodies (or counties, basins, etc.), the map should have location ID's shown for each different waterbody (where the sewer line is within 100 feet of such waterbody - see Instruction VII). This location ID is self chosen and used to cross reference the location in Section C of the permit application.

IX. Stream Classifications – Watershed Classification Attachment (Form WSCAS-12/07) – If any portion of the sewer system project is within 100 feet of any surface water or wetlands, the Watershed Classification Attachment may need to be completed. A variance must be requested for encroachment within required setbacks or buffers pursuant to 2T .0305 (f) and be indicated in Item B-13 with supporting documentation/justification provided.

X. Environmental Assessments – If this project is subject to an Environmental Assessment (EA) [15A NCAC 01C], this application cannot be used. Send the project application on the most current version of Form PSFMGSA to the Design Management Unit, 1633 Mail Service Center, Raleigh, NC 27699-1633. Applications cannot be accepted until a Finding of No Significant Impact (FONSI) or Environmental Impact Statement (EIS) has been issued. A copy is to be submitted with that permit application.

XI. Flow Direction – Many wastewater treatment systems are entering into agreements for regionalization efforts and emergency treatment capacity. Parts of the system are installed so that the wastewater flow can be directed to more than one treatment facility. If this is the case with this project, please indicate in B(12) and give the permit number of the second treatment facility.

XII. Certifications – Section C - The application must be certified by both the applicant and a North Carolina Registered Professional Engineer (PE). The applicant signature must match the signing official listed in Item A(1b). The PE should NOT certify the application if he/she is unfamiliar with 15A NCAC 02T, all applicable State rules and regulations, the Public Works Commission Design Manual and Ordinance (dated March 2002), as applicable to the project. Certification by a PE who is unfamiliar with these documents is subject to NC Board referral.

| |USE THE TAB KEY TO MOVE FROM FIELD TO FIELD! |Application Number: |

| | |(to be completed by PWC) |

|A. |1. Owner/Permittee: |

|APPLICAT| |

|ION | |

|INFORMAT| |

|ION | |

| |1a. |

| |Full Legal Name (company, municipality, HOA, utility, etc.) |

| |1b. |

| |Signing Official Name and Title (Please review 15A NCAC 2T .0106 (b) for authorized signing officials!) |

| |1c. The legal entity who will own this system is: |

| |Individual Federal Municipality State/County Private Partnership Corporation Other (specify): |

| |1d. |1e. |

| |Mailing Address |City |

| |1f. |1g. |

| |State |Zip Code |

| |1h. |1i. |1j. |

| |Telephone |Facsimile |E-mail |

| |2. Project (Facility) Information: |

| | |2b. |

| |2a. |County Where Project is Located |

| |Brief Project Name (permit will refer to this name) | |

| |3. Contact Person: |

| |3a. |

| |Name and Affiliation of Someone Who Can Answer Questions About this Application |

| |3b. |3c. |

| |Phone Number |E-mail |

|B. |1. Project is New Modification (of an existing permit) If Modification, Permit No.: |

|PERMIT | |

|INFORMAT| |

|ION | |

| | |

| |2. Owner is Public (skip to Item B(3)) Private (go to Item 2(a)) |

| | |2b. If sold, facilities owned by a (must choose one) |

| |2a. If private, applicant will be: | |

| |Retaining Ownership (i.e. store, church, single office, etc.) or |Public Utility (Instruction C) |

| |Leasing units (lots, townhomes, etc. - skip to Item B(3)) |Homeowner Assoc./Developer (Instruction D) |

| |Selling units (lots, townhomes, etc. - go to Item B(2b)) | |

| | | |

| | |

| |3. |

| |Owner of Wastewater Treatment Facility (WWTF) Treating Wastewater From This Project |

| | |

| |4. Rockfish WWTF – NC 0050105 Cross Creek WWTF – NC 0023957 |

| | | | |5c. |

| |5a. |5b. ________ |Gravity |Permit # of Downstream Sewer (Instruction VII) |

| |Owner of Downstream Sewer |Receiving Sewer Size |Force Main | |

| | |

| |6. The origin of this wastewater is (check all that apply): |

| | Residential Subdivision | Retail (Stores, shopping centers) |___ % Domestic/Commercial |

| |Apartments/Condominiums |Institution | ___ % Industrial (attach |

| |Mobile Home Park |Hospital |description.) |

| |School |Church |(RO: contact your Regional Office |

| |Restaurant |Nursing Home |Pretreatment staff) |

| |Office |Other (specify):____________ | |

| | | | ___ % Other (specify): |

| | | | |

| | | | |

| |Volume of wastewater to be allocated or permitted for this particular project: ____________ gallons per day |

| |*Do not include future flows or previously permitted allocations |

| | |

| |If the permitted flow is zero, indicate why: |

| | |

| |Pump Station, Outfall or Interceptor Line where flow will be permitted in subsequent permits that connect to this line |

| |Flow has already been allocated in Permit No. _________________ PWC NCDWQ |

| |Rehabilitation or replacement of existing sewer with no new flow expected (see 15A NCAC 02T .0303 to determine if a permit is required) |

| | |

| | |

| | |

|B. |9. Provide the wastewater flow calculations used in determining the permitted flow in accordance with 15A NCAC 2T .0114 for the value in Item B(7) |

|PERMIT |AND/OR the design flow for line or pump station sizing if a reduced or zero flow is being requested in Item B(7). Values other than that in 15A NCAC |

|INFORMAT|2T .0114 (b) and (c) must be supported with actual water or wastewater use data in accordance with 15A NCAC 2T .0114 (f). |

|ION | |

|(CONTINU| |

|ED) | |

| |10. Summary of Sewer Lines to be Permitted (attach additional sheets if necessary) |

| |Size (inches) |Length (feet) |New Gravity or Additional Force Main |

| | | | |

| | | | |

| | | | |

| | | | |

| | |

| | |

| |Summary of Pump Stations w/ associated Force Mains to be Permitted (attach additional sheets as necessary) |

| | |

| | |

| | |

| |Pump Station Location ID ________________________________ (self chosen - as shown on plans/map for reference) |

| | |

| |Design Flow |Operational Point |Power Reliability Option |Force Main Size |Force Main Length |

| |(MGD) |GPM @TDH |1 - permanent generator w/ATS; 2 - | | |

| | | |portable generator w/MTS | | |

| | | | | | |

| | |

| | |

| |Pump Station Location ID_________________________________ (self chosen - as shown on plans/map for reference) |

| | |

| | |

| | |

| |Design Flow |

| |(MGD) |

| | |

| |Operational Point |

| |GPM @TDH |

| |Power Reliability Option |

| |1 - permanent generator w/ATS; 2 - portable generator w/MTS |

| |Force Main Size |

| |Force Main Length |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |Pump Station Location ID_________________________________ (self chosen - as shown on plans/map for reference) |

| | |

| | |

| | |

| |Design Flow |

| |(MGD) |

| | |

| |Operational Point |

| |GPM @TDH |

| |Power Reliability Option |

| |1 - permanent generator w/ATS; 2 - portable generator w/MTS |

| |Force Main Size |

| |Force Main Length |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |12. Will the wastewater flow in the proposed sewer lines or pump stations be able to be directed to another treatment facility? |

| | |

| |Yes No If Yes, permit number of 2nd treatment facility _____________________________ |

| |(RO – if “yes” to B,12 please contact the Central Office PERCS Unit) |

| | |

| | |

| | |

| |13. Does the sewer system comply with the PWC Design Manual’s minimum design criteria, the Gravity Sewer Minimum Design Criteria (latest version) and |

| |15A NCAC Chapter 2T as applicable? |

| | |

| |Yes No If No, please reference the pertinent minimum design criteria or regulation and indicate why a variance is requested. SUBMIT TWO COPIES |

| |OF PLANS, SPECIFICATIONS OR CALCULATIONS PERTINENT TO THE VARIANCE WITH YOUR APPLICATION |

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| |14. Have the following permits/certifications been submitted for approval for the system or project to be served? |

| | |

| |Wetland/Stream Crossings - General Permit or 401Certification? Yes No N/A |

| | |

| |Sedimentation and Erosion Control Plan? Yes No N/A |

| | |

| |Stormwater? Yes No N/A |

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| |15. Does this project include any high priority lines, [see 15A NCAC 02T .0402 (2)] involve aerial lines, siphons, or interference manholes)? These |

| |lines will be considered high priority and must be checked once every six months |

| | |

| |Check if Yes: and provide details |

| | |

| | |

|C. | |

|CERTIFIC|1. Applicant’s Certification: (Signature of Signing Official and Project Name) |

|ATIONS | |

| |I, , attest that this application for has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that|

| |if all required parts of this application are not completed and that if all required supporting documentation and attachments are not included, this |

| |application package is subject to being returned as incomplete. Note: In accordance with North Carolina General Statutes 143-215.6A and 143-215.6B, |

| |any person who knowingly makes any false statement, representation, or certification in any application shall be guilty of a Class 2 misdemeanor, |

| |which may include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation. |

| |1a. |

| |Signing Official Signature |

| |Date |

| | |

| |ENGINEERING DESIGN DOCUMENTS MUST BE COMPLETED PRIOR TO SUBMITTAL OF THIS APPLICATION. THESE DOCUMENTS MUST INCLUDE PLAN AND PROFILE OF SEWERS, THEIR|

| |PROXIMITY TO OTHER UTILITIES, DESIGN CALCULATIONS. ETC. REFER TO 15A NCAC 02T .0305 |

| | |

| |2. Professional Engineer's Certification: (Signature of Design Engineer and Project Name) |

| | |

| |I, , attest that this application for has been reviewed by me and is accurate, complete and consistent with the information in the |

| |engineering plans, calculations, and all other supporting documentation to the best of my knowledge. I further attest that to the best of my |

| |knowledge the proposed design has been prepared in accordance with the applicable regulations, PWC Design Manual, and the watershed classification in |

| |accordance with Division guidance. Although other professionals may have developed certain portions of this submittal package, inclusion of these |

| |materials under my signature and seal signifies that I have reviewed this material and have judged it to be consistent with the proposed design. |

| |Note: In accordance with NC General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement, representation, or |

| |certification in any application shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed $10,000 as well as civil penalties up|

| |to $25,000 per violation. |

| |2a. |NC PE Seal, Signature & Date |

| |Professional Engineer Name | |

| |2b. | |

| |Engineering Firm | |

| |2c. | |

| |Mailing Address | |

| |2d. |2e. |2f. | |

| |City |State |Zip | |

| |2g. |2h. |2i. | |

| |Telephone |Facsimile |E-mail | |

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